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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703322
Report Date: 08/30/2023
Date Signed: 08/30/2023 05:44:40 PM

Document Has Been Signed on 08/30/2023 05:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HELEN'S RESIDENCEFACILITY NUMBER:
421703322
ADMINISTRATOR:HELEN SAN ANTONIO 98FACILITY TYPE:
735
ADDRESS:1653 N ALISONTELEPHONE:
(805) 925-6484
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 3DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Joni San Antonio, Backup AdministratorTIME COMPLETED:
05:55 PM
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Licensing Program Analyst (LPA) Jenny Olson arrived unannounced to conduct a one year required annual inspection. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vince Figueroa. LPA and QAS met with Backup Administrator and explained the reason for the visit.

LPA and QAS toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Records: LPA reviewed client and staff records at 5:00 p.m. LPA reviewed three (3) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. All files were complete

LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2 home. The last disaster drill was conducted on 6/18/2023.

Due to time constraints LPA was unable to finish the annual and will return at another date to continue the annual inspection.



Exit interview completed, copy of report was printed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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